Review Nursing Interventions for the Administration of an Oral Antidepressant
Appropriate Utilise of Psychotropic Drugs in Nursing Homes
Am Fam Doc. 2000 Mar 1;61(5):1437-1446.
Article Sections
- Abstract
- Summary of OBRA Interpretive Guidelines
- Bear on of OBRA on the Prescribing of Psychotropic Drugs
- Recommendations for the Clinical Apply of Psychotropic Drugs
- Final Comment
- References
The Motorbus Budget Reconciliation Deed (OBRA) of 1987 limited the use of psychotropic medications in residents of long-term care facilities. Updates of OBRA guidelines have liberalized some dosing restrictions, simply documentation of necessity and periodic trials of medication withdrawal are all the same emphasized. Antidepressant drugs are typically underutilized in nursing homes. Tricyclic antidepressants have many side effects and thus are not preferred medications in elderly patients. Feet and insomnia are common problems in the institutionalized elderly. If behavioral measures are not successful, antidepressant medications with shorter half-lives may avoid drug accumulation, which tin lead to excessive sedation, cerebral impairment and an increased risk for falls. In the elderly, antipsychotic medications can crusade serious side effects, such every bit extrapyramidal symptoms and tardive dyskinesia. Newer antipsychotic drugs are less ofttimes associated with these side furnishings, simply they should be used only for specific diagnoses and when behavioral and environmental measures are unsuccessful.
Improving the quality of care for nursing domicile residents has been a major business organisation for years. Recently, attention has focused on maximizing the appropriate utilize of psychotropic medications to manage agitation and other behavioral issues associated with dementia.
Mental disorders are present in a large per centum of the nursing home population. Antipsychotics, benzodiazepines and antidepressants are among the medications about commonly used to manage trouble behaviors.1 Historically, antipsychotics and benzodiazepines accept been used excessively (and without appropriate diagnosis or monitoring for side effects) in nursing home residents, often solely for the convenience of staff. Studies have found that most residents of long-term intendance facilities receive at least one psychotropic medication. Meanwhile, antidepressants have been underutilized because low is often overlooked every bit a cause of behavioral disturbances in this population.2
The misuse of psychotropic drugs exposes patients to medication side effects and can pb to deterioration of medical and cognitive status. To combat this problem, the federal regime passed nursing dwelling reform legislation, the Motorbus Budget Reconciliation Act (OBRA) of 1987.3 This legislation is directed at protecting residents of long-term care facilities from medically unnecessary "physical or chemic restraints imposed for purposes of subject field or convenience."3
The Health Care Financing Administration (HCFA), an agency responsible for regulating nursing homes participating in the Medicare and Medicaid programs, adult interpretive guidelines for fulfilling OBRA requirements.four These guidelines were implemented nationally in 1990 and remain in force5 (Figure one).4 Updated guidelines were implemented in July 1999.6
HCFA Guidelines
FIGURE 1.
Summary of the Health Intendance Financing Administration (HCFA) guidelines.
Data from Health Care Financing Administration. Survey procedures and interpretive guidelines for skilled nursing facilities and intermediate care facilities. Baltimore: U.S. Dept. of Health and Human Services, 1990.
Summary of OBRA Interpretive Guidelines
- Abstract
- Summary of OBRA Interpretive Guidelines
- Impact of OBRA on the Prescribing of Psychotropic Drugs
- Recommendations for the Clinical Use of Psychotropic Drugs
- Concluding Comment
- References
All psychotropic drugs (antidepressants, anxiolytics, sedative-hypnotics and antipsychotics) are subject to the "unnecessary drug" regulation of OBRA. According to the HCFA guidelines,4 "residents must be complimentary of unnecessary drugs," which are divers as those that are duplicative, excessive in dose or duration, or used in the presence of adverse effects or without adequate monitoring or indication. The remaining regulations utilise to anxiolytic, allaying-hypnotic and antipsychotic drugs only.
Medical, environmental and psychosocial causes of behavioral problems must be ruled out, and nonpharmacologic direction must exist attempted before psychotropic drugs are prescribed to nursing abode residents. Considering treatment with psychotropic medications is indicated merely to maintain or improve functional status, diagnoses and specific target symptoms or behaviors must be documented, and the effectiveness of drug therapy must be monitored. Specific dosage limits must exist observed, and periodic dosage reductions or drug discontinuations must be undertaken. Side effects (of antipsychotics, in detail) must be monitored. Barbiturates and certain other older tranquilizers may not be prescribed unless they were being used successfully earlier a patient was admitted to a long-term care facility (Tabular array 1).4 Phenobarbital can be used solely to command seizures.
TABLE 1.
Drugs Non to Be Used in Nursing Homes*
| Barbiturates |
| Amobarbital (Amytal) |
| Amobarbital-secobarbital (Tuinal) |
| Aspirin-butalbital-caffeine (Fiorinal) |
| Butabarbital (Butisol) |
| Pentobarbital (Nembutal) |
| Secobarbital (Seconal) |
| Other tranquilizers |
| Ethclorvynol (Placidyl) |
| Glutethimide (Doriden) |
| Meprobamate (Miltown) |
OBRA restricts the utilise of antipsychotic drugs just in patients with dementia. None of the OBRA dosage restrictions or monitoring requirements utilize in patients with psychotic disorders (e.g., schizophrenia).
Each nursing dwelling is surveyed annually. Because facilities that do not meet HCFA'due south legislated requirements may exist denied Medicare reimbursement,7 physicians who prescribe medications for nursing home residents must document the medical necessity of noncompliance with regulations (e.yard., drug prescriptions in excess of OBRA-mandated dosages). Equally a resource for physicians and facilities, a local consultant pharmacist reviews all charts monthly and assists with compliance.
Co-ordinate to the OBRA strategy, the long-term care facility, rather than the prescribing physician, is accountable for monitoring drug utilise.8 Some consider that this approach better reflects the realities of nursing habitation practice, in that the prescribing doc only visits the facility occasionally.8 Regardless of where final responsibility lies, physicians demand to be aware of the HCFA interpretive guidelines for the fulfillment of OBRA requirements.
The updated HCFA regulations change some antipsychotic dosing restrictions.6 Medications considered potentially chancy to the elderly are listed in Tables 2 and 3.ix
Table 2.
Drugs with a High Potential for Severe Outcomes in the Elderly
| Drugs | Comments |
|---|---|
| Psychotropics | |
| Amitriptyline (Elavil) | Strongly anticholinergic and sedating |
| Barbiturates | More side effects than most sedative-hypnotic drugs; should not be used except to control seizures (phenobarbital) |
| Long-acting benzodiazepines | Long half-life and, hence, prolonged sedation; associated with an increased incidence of falls and fractures |
| Doxepin (Sinequan) | Strongly anticholinergic and sedating |
| Meprobamate (Miltown) | Highly addictive and sedating |
| Analgesics | |
| Meperidine (Demerol) | Not constructive when administered orally; metabolite has anticholinergic profile |
| Pentazocine (Talwin) | Defoliation and hallucinations more mutual than with other narcotics |
| Miscellaneous | |
| Antispasmodic agents (gastrointestinal) | Highly anticholinergic with associated toxic effects |
| Chlorpropamide (Diabinase) | Serious hypoglycemia possible because of the drug'south prolonged one-half-life |
| Digoxin (Lanoxin) | Decreased renal clearance; doses should rarely exceed 0.125 mg except when treating arrhythmias |
| Methyldopa (Aldomet) | Causes bradycardia and exacerbates low |
| Ticlopidine (Ticlid) | More toxic than aspirin |
TABLE 3.
Drugs with a High Potential for Less Severe Outcomes in the Elderly
| Drugs | Comments |
|---|---|
| Analgesics | |
| Indomethacin (Indocin) | More than central nervous system side furnishings than any other nonsteroidal anti-inflammatory drug |
| Propoxyphene (Darvon) | Few advantages over acetaminophen and has narcotic side effects |
| Antihypertensives | |
| Beta blockers | Can crusade problems in patients with asthma or chronic obstructive pulmonary disease; may precipitate syncope because of negative inotropic and chronotropic effects |
| Reserpine* | Tin crusade low, sedation and orthostatic hypotension |
| Miscellaneous | |
| Antihistamines† | Highly anticholinergic |
| Cyclandelate (Cyclospasmol) | Generally ineffective for dementia or any other condition |
| Dipyridamole (Persantine) | Oftentimes causes orthostatic hypotension; of do good merely in patients with artificial heart valves |
| Ergoloid mesylates (Hydergine) | More often than not ineffective for dementia or any other condition |
| Muscle relaxants | Increased cholinergic activeness, sedation and weakness |
| Trimethobenzamide (Tigan) | Least effective antiemetic and tin cause extrapyramidal symptoms |
Impact of OBRA on the Prescribing of Psychotropic Drugs
- Abstract
- Summary of OBRA Interpretive Guidelines
- Touch of OBRA on the Prescribing of Psychotropic Drugs
- Recommendations for the Clinical Employ of Psychotropic Drugs
- Last Comment
- References
Several multiyear, multifacility reviews accept examined the bear upon of OBRA regulations on the prescribing of psychotropic drugs in nursing homes.2,seven,viii,10,eleven Researchers confirm an encouraging trend toward increased awareness of the indications for neuroleptic drugs and the side effects of these medications.2
Since OBRA was enacted, overall use of antipsychotic drugs in nursing habitation residents has declined by nigh one 3rd,x and prescriptions for antidepressants have increased8 (past nigh 85 per centum in ane study10). Furthermore, selective serotonin reuptake inhibitors (SSRIs), nortriptyline (Pamelor) and trazodone (Desyrel) are beingness prescribed significantly more oft, and amitriptyline (Elavil) and doxepin (Sinequan) are being used less often.8
The prescribing patterns for anxiolytic and sedative-hypnotic drugs are less consistent. I large report documented a 12 percent increase in prescriptions for anxiolytics but found decreases in the prescribing of item agents, such as diazepam (Valium) and diphenhydramine (Benadryl).eight Two studies2,7 unequivocally cited the implementation of OBRA regulations, rather than other educational and consultative interventions, equally being responsible for decreased use of neuroleptic drugs and lower dosages of these agents when they are used.
A recent review11 found that specific guidelines (on appropriate diagnosis, target symptom documentation and reasonable dosage level) were widely followed, with compliance rates ranging from 70 to 90 percent. Less specific guidelines (on attempts to use nonpharmacologic interventions and the monitoring of drug efficacy and safety) were less well followed, with compliance rates below 55 per centum.
Recommendations for the Clinical Apply of Psychotropic Drugs
- Abstruse
- Summary of OBRA Interpretive Guidelines
- Affect of OBRA on the Prescribing of Psychotropic Drugs
- Recommendations for the Clinical Use of Psychotropic Drugs
- Final Comment
- References
Prescribed judiciously, psychotropic drugs can enhance the physical and psychologic well-being of the elderly. However, altered drug disposition makes this age group peculiarly sensitive to undesirable side furnishings, which can lead to a decline in medical and functional status or the utilise of boosted prescriptions and an increased adventure of drug interactions. Psychotropic medications, including side effects and recommendations on utilise in the elderly, are briefly reviewed in the following sections.
ANTIDEPRESSANT DRUGS
OBRA requirements for the prescribing of antidepressant drugs are limited. The legislation mandates only documentation of an appropriate diagnosis, utilize of a reasonable dosage (Tabular array iv), clinically acceptable elapsing of use and monitoring for common adverse reactions.
TABLE iv.
Antidepressant Drugs and Dosages Preferred for Use in the Elderly
| Drugs | Geriatric dosage (mg per 24-hour interval) | Side effects | ||||
|---|---|---|---|---|---|---|
| Starting dosage | Maintenance dosage | Sedation | Agitation | Anticholinergic effects | Orthostatic hypotension | |
| Tricyclic antidepressants | ||||||
| Desipramine (Norpramin) | 25 | 50 to 150 | Low | Low | Low | Low |
| Nortriptyline (Pamelor) | 10 to 25 | 40 to 75 | Moderate | — | Depression | Low |
| Selective serotonin reuptake inhibitors | ||||||
| Citalopram (Celexa) | 20 | twenty to 40 | Depression | Low | — | — |
| Fluvoxamine (Luvox) | 50 | 50 to 200 | Low | Low | — | — |
| Paroxetine (Paxil) | 10 | 20 to 30 | Low | Low | — | — |
| Sertraline (Zoloft) | 25 to 50 | 50 to 150 | Low | Low | — | — |
| Miscellaneous | ||||||
| Bupropion (Wellbutrin) | 100 | 100 to 400 | — | Moderate | — | Depression |
| Nefazodone (Serzone) | 100 | 100 to 600 | Moderate | — | Low | Depression |
| Trazodone (Desyrel) | 25 to 50 | 50 to 300 | High | — | Low | Moderate |
| Venlafaxine (Effexor) | 75 | 75 to 350 | Low | Low | Depression | Depression |
Yet, choosing antidepressants with suitable side outcome profiles is of import in geriatric patients. The older tricyclic antidepressants, although highly effective, accept side effects to which the elderly are specially sensitive. Of particular concern are excessive sedation, anticholinergic effects (dry oral fissure, constipation, urinary retention, blurred near vision, tachycardia and confusion), orthostatic hypotension and electrocardiographic changes. In elderly patients, it is better to utilize tricyclic antidepressants that cause less astringent anticholinergic effects and orthostatic hypotension, such every bit nortriptyline and desipramine (Norpramin).
Subtle differences amongst SSRIs should as well exist considered. The half-lives reported for fluoxetine (Prozac) and its active metabolite are long (84 and 146 hours, respectively).12 Considering of fluoxetine'southward long half-life and the persistence of side furnishings (sometimes for weeks after discontinuation), this drug is mostly not recommended for use in elderly patients. Sertraline (Zoloft) and its metabolite have considerably shorter half-lives (25 and 66 hours, respectively). Paroxetine (Paxil), which has no agile metabolite, as well has a considerably shorter half-life (24 hours) than fluoxetine.12,13
Most SSRIs are associated with significant drug interactions. Fluoxetine, paroxetine and, to a lesser extent, sertraline inhibit the metabolism of warfarin (Coumadin), cisapride (Propulsid), benzodiazepines, quinidine, tricyclic antidepressants, theophylline and some statins.12 In patients at take a chance for these interactions, citalopram (Celexa), a new SSRI now available in the The states, may offering an advantage. Studies have shown that compared with other SSRIs, citalopram has less of an inhibitory effect on the cytochrome P450 system.14 Citalopram is as effective as fluoxetine and sertraline in the handling of depression.14
Trazodone and nefazodone (Serzone) are also recommended for utilize in the elderly. Both of these drugs are fairly sedating (trazodone more so than nefazodone) and therefore are useful in elderly patients with depression and agitation or insomnia. Considering trazodone is associated with significant orthostatic hypotension, nighttime dosing may exist preferable. If trazodone causes excessive sedation or postural hypotension, nefazodone is an alternative. Even so, nefazodone inhibits the cytochrome P450 3A4 pathway, and it may exhibit dangerous interactions with cisapride.12
Venlafaxine (Effexor) and bupropion (Wellbutrin) are constructive, well-tolerated antidepressants that lack pregnant anticholinergic side effects. Because bupropion is structurally related to stimulants, bedtime administration should be avoided. Bupropion in dosages above 400 mg per twenty-four hours is associated with seizures.12 In dosages exceeding 200 mg per day, venlafaxine causes increased blood pressure in 3 to thirteen percent of patients.12 Therefore, higher dosages of these drugs are not recommended.
The tetracyclic drug mirtazapine (Remeron) is another newer antidepressant. This drug is a weak blocker of alpha-adrenergic and muscarinic receptors. Considering of these actions, mirtazapine tin can cause orthostatic hypotension and anticholinergic effects; notwithstanding, these side effects are less severe than those occurring with tricyclic antidepressants. Somnolence has been reported past more than l percent of patients treated with mirtazapine.15 Research on the use of this drug in geriatric patients has been limited.12,fifteen
Most antidepressants accept a long enough one-half-life in the elderly that they may be given as a unmarried dose in the morning time or evening, depending on the sedative or activating properties of the detail drug. Dosages need to be titrated carefully: the more than gradual the titration, the lower the likelihood of side furnishings.
Typical antidepressant dosage ranges are one half of those used in younger patients. Occasionally, even so, a full dosage is needed to yield a therapeutic consequence.
ANXIOLYTIC AND Sedative-HYPNOTIC DRUGS
Benzodiazepines are indicated for the short-term management of anxiety and insomnia, but nonpharmacologic measures should be tried first. Emphasizing good slumber habits is a offset step and should include decreasing afternoon caffeine intake, exercising regularly before dinner, avoiding naps, establishing regular sleep hours, treating nighttime pain, addressing nocturia and maintaining a comfortable chamber surround (temperature, noise level, lighting, etc.).
When benzodiazepine therapy becomes necessary for older patients, it is preferable to use short-interim agents. Elderly patients can better tolerate temazepam (Restoril) and lorazepam (Ativan), which accept relatively brusk half-lives (three to 18 hours and 10 to 16 hours, respectively) and relatively short durations of action.16,17 Long-acting benzodiazepines, which have half-lives that may exceed 100 hours, behave higher risks for elderly patients. Indeed, the continuous assistants of a long-acting benzodiazepine can pb to profound defoliation, cognitive impairment and falls. For this reason, OBRA guidelines let the use of long-acting benzodiazepines in residents of long-term intendance facilities only if a trial of short-interim benzodiazepines fails.
Side effects of all benzodiazepines include excessive sedation, psychomotor slowing, cerebral damage, confusion, forgetfulness, morn "hangover" issue, ataxia and falls. Occasionally, dysphoria, irritability and agitation develop in elderly patients treated with these drugs.16
Zolpidem (Ambien) is a newer medication with some advantages as a short-term sleep aid for the elderly. Compared with benzodiazepines, zolpidem appears to carry less risk for the development of tolerance, withdrawal phenomenon or rapid-eye-movement rebound. Side furnishings of zolpidem include drowsiness, dizziness, headache and gastrointestinal upset.17
OBRA regulations permit the use of antihistamines such as diphenhydramine and hydroxyzine (Atarax, Vistaril) for the management of anxiety and insomnia in elderly patients. However, even in low dosages, these drugs are associated with harm of daytime performance.17 Furthermore, the anticholinergic furnishings of antihistamines (delirium, defoliation, disorientation, etc.) may exacerbate problem behaviors.17
Sedating antidepressants in low dosages are often used to treat insomnia. Nortriptyline (in a dosage of 10 to 25 mg per day) and particularly trazodone (in a dosage of 25 to 150 mg per day), which exhibits no anticholinergic effects, are well suited for use in geriatric patients.17
OBRA-specified dosages of unremarkably used anxiolytic and sedative-hypnotic drugs are listed in Tabular array 5.
Table 5.
Anxiolytic and Allaying-Hypnotic Drugs Commonly Used in the Elderly
| Drugs | Geriatric dosage (mg per day)* | |||
|---|---|---|---|---|
| Anxiety | Insomnia | Onset of activeness | ||
| Short-acting agents | ||||
| Benzodiazepines | ||||
| Alprazolam (Xanax) | 0.75 | 0.25 | Intermediate | |
| Estazolam (Prosom) | 0.5 | 0.5 | Fast | |
| Lorazepam (Ativan) | 2 | ane | Intermediate | |
| Oxazepam (Serax) | 30 | 15 | Slow | |
| Temazepam (Restoril) | — | fifteen | Intermediate | |
| Triazolam (Halcion) | — | 0.125 | Fast | |
| Antihistamines | ||||
| Diphenhydramine (Benadryl) | fifty | 25 | Fast | |
| Hydroxyzine (Atarax) | 50 | 50 | Fast | |
| Miscellaneous | ||||
| Zolpidem (Ambien) | — | v | Fast | |
| Long-acting agents | ||||
| Benzodiazepines | ||||
| Chlordiazepoxide (Librium) | 20 | 20 | Intermediate | |
| Clonazepam (Klonopin) | 1.5 | 1.5 | Intermediate | |
| Clorazepate (Tranxene) | 15 | 15 | Fast | |
| Diazepam (Valium) | 5 | 5 | Very fast | |
| Flurazepam (Dalmane) | fifteen | 15 | Very fast | |
| Halazepam (Paxipam) | forty | 20 | Slow | |
| Prazepam (Centrax) | 15 | 15 | Boring | |
| Quazepam (Doral) | vii.5 | 7.5 | Intermediate | |
ANTIPSYCHOTIC DRUGS
Because of their many deleterious side effects, antipsychotics should exist used merely every bit a last resort in the management of behavioral problems in the elderly (Table 6). The efficacy of these drugs for most trouble behaviors is debatable. In several studies,5,viii antipsychotics take been no more constructive than placebo. Some investigators believe that antipsychotic drugs should be used only for the management of psychotic features that cause patients "serious distress."7
TABLE half-dozen.
Antipsychotic Drugs Commonly Used in the Elderly
| Drugs | Geriatric dosage (mg per 24-hour interval)* | Side effects | ||||
|---|---|---|---|---|---|---|
| Sedation | Extrapyramidal effects | Anticholinergic effects | Orthostatic hypotension | Tardive dyskinesia | ||
| Phenothiazines | ||||||
| Chlorpromazine (Thorazine) | 75 | High | Moderate | Moderate | Loftier | Yes |
| Fluphenazine (Prolixin) | iv | Low | High | Low | Low | Yep |
| Mesoridazine (Serentil) | 25 | High | Depression | High | Moderate | Aye |
| Prochlorperazine (Compazine) | 10 | Moderate | High | Low | Low | Yes |
| Promazine (Sparine) | 150 | Moderate | Moderate | Loftier | Moderate | Yes |
| Trifluoperazine (Stelazine) | eight | Low | Loftier | Depression | Low | Yes |
| Triflupromazine (Vesprin) | 20 | Loftier | Moderate | High | Moderate | Aye |
| Thioridazine (Mellaril) | 75 | High | Low | High | Loftier | Yes |
| Thioxanthene | ||||||
| Thiothixine (Navane) | 7 | Low | Loftier | Depression | Moderate | Yes |
| Butyrophenone | ||||||
| Haloperidol (Haldol) | 4 | Low | Very high | Low | Depression | Yep |
| Dibenzoxazepine | ||||||
| Loxapine (Loxitane) | 10 | Low | Moderate | Low | Low | Aye |
| Dihydroindolone | ||||||
| Molindone (Moban) | 10 | Moderate | Moderate | Depression | Low | Yes |
| Singular antipsychotics | ||||||
| Clozapine (Clozaril) | 50 | High | Depression | High | Moderate | Depression |
| Olanzapine (Zyprexa) | 10 | Moderate to high | Low | Moderate to loftier | Moderate | Low |
| Quetiapine (Seroquel) | 200 | Moderate | Depression | High | Moderate | Depression |
| Risperidone (Risperdal) | two | Depression | Low | Low | Low | Low |
Mutual side effects of antipsychotics include sedation, anticholinergic furnishings, orthostatic hypotension, extrapyramidal symptoms and tardive dyskinesia. Extrapyramidal symptoms include dystonic reactions, pseudoparkinsonism and akathisia. All extrapyramidal symptoms are reversible on discontinuation of antipsychotic drugs.
Dystonic reactions are acute spasms of muscle groups and tin outcome in a stock-still up gaze, neck twisting, facial musculus spasms causing grimacing, a clenched jaw and difficulty with speech. Oft painful, dystonic reactions can be quite frightening to patients. These reactions typically occur soon after an antipsychotic drug is initiated.
Pseudoparkinsonism presents with classic parkinsonian symptoms such every bit rigidity, slowed movements, shuffling gait, ho-hum, monotonous speech and pill-rolling tremor. The symptoms develop over a few weeks of antipsychotic drug therapy.
Akathisia is a form of agitation. Symptoms include disability to sit down still, pacing, restlessness, foot tapping, and rocking and shifting of weight while continuing. It tin be hard to distinguish akathisia from the agitation that is often present in patients with dementia. Akathisia mostly appears days after the initiation of an antipsychotic medication.
Although often considered an extrapyramidal symptom, tardive dyskinesia is a dissever, mechanistically distinct phenomenon. It is a long-term side result that may persist later an antipsychotic drug is discontinued. Typical symptoms are rhythmic involuntary movements of the tongue, lips or jaw, such as protrusion of the natural language or puckering of the lips. Irregular involuntary movements of the extremities or spine are likewise possible. All traditional antipsychotics may cause tardive dyskinesia.
Older neuroleptic drugs are classified as loftier, moderate or depression potency. Antipsychotic drugs with higher potency have a greater affinity for dopamine receptors and tend to crusade more extrapyramidal symptoms. Antipsychotics with lower potency have a greater affinity for histaminic, blastoff-adrenergic and muscarinic receptors. These drugs are more likely to cause increased sedation, orthostatic hypotension and anticholinergic effects. Elderly patients are sensitive to all these side effects.
Mounting evidence indicates that newer antipsychotics given in low dosages are much less probable to cause extrapyramidal symptoms.18 These drugs, which include clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal), have a greater affinity for dopamine-Dtwo receptors and are potent antagonists of the serotonin receptor.
Clozapine, olanzapine and, to a lesser extent, quetiapine may cause sedation, anticholinergic effects and orthostatic hypotension. Quetiapine has not been studied in the elderly.eighteen How this drug compares with other newer antipsychotics remains to be established.19 Risperidone is well tolerated,eighteen and several studies accept demonstrated its efficacy in the management of psychotic and aggressive symptoms in patients with dementia.18,20 Risperidone, in dosages of 0.5 to 1.0 mg per day, has successfully alleviated behavioral disturbances in patients with Alzheimer's affliction.21,22 Clozapine is somewhat more hard to utilise because of its clan with agranulocytosis and the need for periodic monitoring of complete blood counts.
Last Comment
- Abstruse
- Summary of OBRA Interpretive Guidelines
- Affect of OBRA on the Prescribing of Psychotropic Drugs
- Recommendations for the Clinical Utilise of Psychotropic Drugs
- Final Comment
- References
Psychotropic medications are sometimes required to maximize quality of life and functional status in nursing home residents. In tailoring pharmacologic regimens for these patients, physicians need to requite careful attention to accurate diagnosis, advisable dosing, side furnishings, drug interactions and pertinent drug pharmacokinetics. An ongoing evaluation of effectiveness requires reassessment at regular intervals to rethink medication regimens in lite of changes in the wellness condition of geriatric patients.
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REFERENCES
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1. Christensen DB, Benfield WR. Alprazolam as an alternative to depression-dose haloperidol in older, cognitively impaired nursing facility patients. J Am Geriatr Soc. 1998;46:620–five. ...
2. Siegler EL, Capezuti E, Maislin Chiliad, Baumgarten One thousand, Evans L, Strumpf Northward. Effects of a restraint reduction intervention and OBRA '87 regulations on psychoactive drug use in nursing homes. J Am Geriatr Soc. 1997;45:791–6.
iii. Coach Budget Reconciliation Act of 1987: subtitle C, nursing home reform: PL100-203. Washington, D.C.: National Coalition for Nursing Home Reform, 1987.
four. Health Care Financing Administration. Survey procedures and interpretive guidelines for skilled nursing facilities and intermediate care facilities. Baltimore: U.S. Dept. of Health and Human Services, 1990.
5. Harrington C, Tompkins C, Curtis M, Grant L. Psychotropic drug employ in long-term care facilities: a review of the literature. Gerontologist. 1992;32:822–33.
6. Nursing home survey procedures and interpretive guidelines. second ed. Alexandria, Va.: American Society of Consultant Pharmacists, 1999.
7. Slater EJ, Glazer Westward. Use of OBRA–87 guidelines for prescribing neuroleptics in a VA nursing home. Psychiatr Serv. 1995;46:119–21.
8. Borson S, Doane K. The touch on of OBRA–87 on psychotropic drug prescribing in skilled nursing facilities. Psychiatr Serv. 1997;48:1289–96.
ix. Beers Thousand. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Curvation Intern Med. 1997;157:1531–6.
10. Lantz MS, Giambanco 5, Buchalter EN. A ten-year review of the outcome of OBRA–87 on psychotropic prescribing practices in an academic nursing home. Psychiatr Serv. 1996;47:951–five.
xi. Llorente MD, Olsen EJ, Leyva O, Silverman MA, Lewis JE, Rivero J. Utilize of antipsychotic drugs in nursing homes: current compliance with OBRA regulations. J Am Geriatr Soc. 1998;46:198–201.
12. Hay DP, Rodriguez MM, Franson KL. Treatment of depression in late life. Clin Geriatr Med. 1998;xiv:33–46.
xiii. Drug facts and comparisons. St. Louis: Facts and Comparisons, 1999;264j.
xiv. Citalopram for depression. Med Lett Drugs Ther. 1998;40:113–iv.
fifteen. Mirtazapine—a new antidepressant. Med Lett Drugs Ther. 1996;38:113–4.
16. Burke WJ, Folks DG, McNeilly DP. Effective use of anxiolytics in older adults. Clin Geriatr Med. 1998;14:47–65.
17. Folks DG, Burke WJ. Psychotherapeutic agents in older adults. Sedative hypnotics and sleep. Clin Geriatr Med. 1998;14:67–86.
eighteen. Finkel SI. Psychotherapeutic agents in older adults. Antipsychotics: old and new. Clin Geriatr Med. 1998;14:87–100.
19. Quetiapine for schizophrenia. Med Lett Drugs Ther. 1997;39:117–8[Published erratum in Med Lett Drugs Ther 1998;40:twenty]
20. Berman I, Merson A, Rachov-Pavlov J. Risperidone in elderly psychiatric patients: an open-labeled trial. Am J Geriatr Psychiatry. 1996;iv:173–nine.
21. Kumar 5, Durai UN, Jobe T. Pharmacologic management of Alzheimer's disease. Clin Geriatr Med. 1998;fourteen:129–46.
22. Kumar 5. Use of atypical antipsychotic agents in geriatric patients: a review. Int J Geriatr Psychopharmacol. 1997;1:15–23.
Richard W. Sloan, M.D., R.PH., coordinator of this series, is chairman and residency program director of the Department of Family Medicine at York (Pa.) Hospital and clinical associate professor in family and community medicine at the Milton South. Hershey Medical Eye, Pennsylvania Country University, Hershey, Pa.
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